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APPLICATION FOR PERIi;T SAN JOAQU-1I+ LOCAL HcALTH DISTRICT 3 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 i GATE ISSUED A��1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health Distract for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the/San Joaquin Local Health District. Job Address Subdivision Name Owner's Namet Address Phone Contractor's Name (�}/� ,f ca��r License No. 2 j� 3�[3 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing "1 Irrigation Approx. Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal �f ❑Geophysical Type of Grout LJOther Surface Seal Installed by �+ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) {! G Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is a available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms 3 Lot size L/ Character of soil to a depth of 3 feet: en Z" Water table depth 'L�_ r SEPTIC TANK Type/Mfg Capacity %�.Q'>� No. Compartments Z— PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal +' SEWAGE SYSTEM �—I Distance to nearest: Well �Op Foundation a 4_. Property Line Z� DESTRUCTION LEACHING LINE No. & Length of lines VC7 Or Total length/size FILTER BED ❑` Distance to nearest: Well Fourdation Property Line SEEPAGE PITS Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line —,, - DISPOSAL PONDS ❑ I } I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman s. compensation laws of California." Contractor's hiring or sub-contracting.signature certifies the following: "I certify that in the performance of the work for which I this permit is issued, I shall-employ persons subject to workman's compensation laws of California." The applicant m St c411 or all quired i t' ns. Complete dra on ever Signed X o. Title: /.+ss Date: OR RRTMENT USE ONLY Application Accepted by Area _ i Q Stk 466-67$i Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection'by r' Date `� /-� ❑ Manteca 823-7104 Final Inspection by Date ' ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16 1 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 LEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. 10/82 500 EH 13-24 REV. 10/82 14-26